Impact of a Family Information Leaflet on Effectiveness
of Information Provided to Family Members of Intensive
Care Unit Patients
A Multicenter, Prospective, Randomized, Controlled Trial
ELIE AZOULAY, FRÉDÉRIC POCHARD, SYLVIE CHEVRET, MERCÉ JOURDAIN, CAROLINE BORNSTAIN, ANNE WERNET,
ISABELLE CATTANEO, DJILALI ANNANE, FRÉDÉRIC BRUN, PIERRE-EDOUARD BOLLAERT, JEAN-RALPH ZAHAR,
DANY GOLDGRAN-TOLEDANO, CHRISTOPHE ADRIE, LUC-MARIE JOLY, JEROME TAYORO, THIBAUT DESMETTRE,
ETIENNE PIGNE, ANTOINE PARROT, OLIVIER SANCHEZ, CATHERINE POISSON, JEAN-ROGER LE GALL,
BENOÎT SCHLEMMER, and FRANÇOIS LEMAIRE for the French FAMIREA Group
Intensive Care and Biostatistics Departments of the Saint-Louis Teaching Hospital and Paris 7 University; Intensive Care Unit of the Cochin
Teaching Hospital, Paris; Intensive Care Unit of the Henri Mondor Teaching Hospital, Créteil, France; and the Ethics Committee of the French
Society for Critical Care
Comprehension and satisfaction are relevant criteria for evaluat-
ing the effectiveness of information provided to family members
of intensive care unit (ICU) patients. We performed a prospective
randomized trial in 34 French ICUs to compare comprehension of
diagnosis, prognosis, treatment, and satisfaction with information
provided by ICU caregivers, in ICU patient family representatives
who did (n  87) or did not (n  88) receive a family information
leaflet (FIL) in addition to standard information. An FIL designed
specifically for this study was delivered at the first visit of the fam-
ily representative: it provided general information on the ICU and
hospital, the name of the ICU physician caring for the patient, a
diagram of a typical ICU room with the names of all the devices,
and a glossary of 12 terms commonly used in ICUs. Characteristics
of the ICUs, patients, and family representatives were similar in
the two groups. The FIL reduced the proportion of family mem-
bers with poor comprehension from 40.9% to 11.5% (p  0.0001).
In the representatives with good comprehension, the FIL was asso-
ciated with significantly better satisfaction (21 [18 to 24, quartiles]
versus 27 [24 to 29, quartiles], p  0.01). These results indicate
that ICU caregivers should consider using an FIL to improve the ef-
fectiveness of the information they impart to families.
Keywords: family needs; satisfaction; comprehension; leaflet; informa-
tion; intensive care
An important task for intensive care unit (ICU) physicians is
to provide family members with the appropriate, clear, and
compassionate information they need to cope with their dis-
tress and to participate in making decisions about patients
who are unable to speak for themselves. Previous studies,
from both the United States and Europe, have shown that the
quality of information provided to family members of ICU pa-
tients can be assessed based on two criteria, namely, compre-
hension (1) and satisfaction with the information provided by
ICU caregivers to family members (2–5). Family members
must understand the diagnosis, prognosis, and treatment in
(Received in original form August 29, 2001; accepted in final form October 12, 2001)
Supported by a grant from the French Society for Critical Care.
Correspondence and requests for reprints should be addressed to Élie Azoulay,
M.D., Service de réanimation médicale, Hôpital Saint-Louis, 1 avenue Claude
Vellefaux 75010 Paris, France. E-mail: elie.azoulay@sls.ap-hop-paris.fr
This article has an online data supplement, which is accessible from this issue’s
table of contents online at www.atsjournals.org
Am J Respir Crit Care Med Vol 165. pp 438–442, 2002
DOI: 10.1164/rccm.200108-006OC
Internet address: www.atsjournals.org
the patient if they are to participate in management decisions
(6–8) and to speak for the patient. Moreover, good compre-
hension helps the family cope with the psychological stress as-
sociated with the ICU admission (1). Satisfaction of family
members promotes favorable interactions with caregivers
seeking to meet the needs of the family (2–5, 9). Previous
studies of the quality of information provided to family mem-
bers of ICU patients were mainly descriptive, although they
also identified the determinants of comprehension and satis-
faction in the family. Comprehension was associated with pa-
tient’s age, delivery of a family information leaflet (FIL), and
caregivers’ perception of poor comprehension (1). Satisfaction
was greater when the patient/nurse ratio was less than 3; when
the family felt they received no contradictory information,
knew the specific role of each caregiver, or were helped by
their usual physician; and when the interview time allowed to
the family increased. There are no published studies of the ef-
fects on comprehension and satisfaction of interventions de-
signed specifically to improve the effectiveness of information
provided to families of ICU patients.
In previous studies, which were not randomized, handing
an information leaflet to the family members during the first
interview improved comprehension (1), although the effect on
satisfaction was inconsistent (2). These studies were con-
ducted each in a single ICU, in small numbers of families (1).
Some used but did not evaluate the benefits of an information
leaflet (10, 11). Moreover, delivery of the information leaflet
to the family members was not strictly controlled in any of
these studies (2, 12).
We sought to determine whether a standardized FIL im-
proved satisfaction and comprehension of the information
provided to family members of ICU patients.
METHODS
Study Design
ICU selection. From a total of 114 French ICUs, members of the
French Society for Critical Care, we randomly selected 51 ICUs, strat-
ifying on university versus community hospital and on the city (Paris
area versus others). An invitation to participate in the study was sent
to the heads of these 51 ICUs. A physician in each center (the investi-
gator) collected ICU and patient characteristics on standardized forms.
Inclusion criterion. The only eligibility criterion for each patient
was the expected length of ICU stay, which was required to be at least
48 h. Each participating ICU included six consecutive patients meet-
ing this criterion, starting on July 1, 2000. The number of patients per
center was limited to six (including three with no FIL) because a
Azoulay, Pochard, Chevret, et al.: Family Information Leaflet
previous study showed that receiving an FIL had an independent fa-
vorable effect on comprehension by family members of ICU patients
(1), and to avoid any center effect on study results.
Exclusion criteria. Patients were excluded from the study if (1)
they died within 48 h after ICU admission, (2) their family representa-
tives refused to participate in the study, or (3) no family members vis-
ited them within 5 d after their admission to the ICU.
Randomization procedure. Computer-generated random-number
tables were used to assign patients to the FIL or control group in
blocks of six stratified on ICU. Each participating ICU received six
sealed envelopes, of which three contained an FIL and three a blank
sheet. To ensure full concealment of allocation, a biostatistics depart-
ment independent from the study ICUs carried out the randomization
procedure, prepared the envelopes, and sent them to the study ICUs.
Consecutive patients whose length of stay in the ICU was expected to
be longer than 48 h were randomized at admission. Family represen-
tatives of control patients were informed according to routine practice
in the ICU before the study (“standard information,” including at
least one meeting with a physician each day during the first week of
ICU admission, with information on the diagnosis, prognosis, and
treatment). Family representatives in the FIL group received stan-
dard information and an FIL. At the first visit of the family represen-
tative to the ICU, an ICU caregiver other than the investigator
opened a sealed envelope and, if it contained an FIL, handed this doc-
ument to the family representative. Then, assessment of comprehen-
sion (1) and satisfaction (see Appendix E1 in the online data supple-
ment) (2, 3), and of anxiety and depression, were performed between
the third and the fifth day.
Further details on data collection, description of the standardized
family information leaflet, and instruments used to measure the effec-
tiveness of information provided to family representatives can be
found in the online data supplement.
Statistical Analysis
Results are expressed as quartiles. Comprehension in the two groups
was compared using the chi-square test, or the Fisher exact test when
appropriate. Comparison of satisfaction in the two randomized groups
was performed using the nonparametric Mann-Whitney test. All p val-
ues were two-sided, with values of 0.05 or less indicating statistical sig-
nificance. All statistical tests were done using the SAS 6.12 (SAS Inc.,
Cary, NC) package.
Sample Size
Sample size was computed on the basis of previous results, suggesting
that the FIL would improve comprehension by approximately 20%
but would not influence satisfaction (1). To detect a 20% difference
from a 50% noncomprehension rate without the FIL (i.e., 50% versus
30%), with a type I error of 0.05 and a power of 0.80, 204 patients had
to be recruited, 102 in each group.
Figure 1. Study profile.
439
RESULTS
A total of 34 ICUs (442 beds) participated in the study and in-
cluded a total of 204 patients (Figure 1). Eight patients died be-
fore their family members could be invited to complete the
questionnaire, and 15 additional patients received no visits
within the first 5 d after ICU admission. This left 181 family rep-
resentatives, of whom 175 (97%) accepted and 6 (3%) declined
to be interviewed about their comprehension and to complete
the Critical Care Family Needs Inventory (CCFNI) question-
naire. Thus, the study data were obtained from 175 family repre-
sentatives. A single ICU had two excluded patients (one in each
randomized group); each of the other ICUs had one excluded
patient at the most. Randomization of the patients at admission
assigned 88 family representatives to the FIL group and 87 to
the control group. The ICU physicians and nurses who collected
the study data constitute the French FAMIREA group.
Characteristics of the 34 ICUs
As shown in Table 1, 17 (50%) ICUs were both medical and
surgical, 15 (44%) were medical, and two (6%) were surgical.
In 16 (47%) ICUs, it was standard practice for the physicians
and nurses to meet regularly to discuss family needs. Only in 6
(18%) ICUs was information about a given patient provided
by the same physician throughout the patient’s ICU stay.
None of the collected parameters were significantly different
between the two randomized groups.
Characteristics of the 175 Patients
Median age was 60 yr (range, 48 to 71) (Table 2). Thirty-nine
(22%) patients were not of French descent. Median Simplified
Acute Physiology Score (SAPS II) at admission was 41 (29 to
55), length of ICU stay was 9 (6 to 17) d, and in-ICU mortality
was 25% (44 deaths). None of the collected parameters were
significantly different in the two randomized groups.
Characteristics of the 175 Family Members Who Completed
the Questionnaires
Although 40 (23%) family members were not of French de-
scent (Table 3), all spoke French. Of the 175 family members,
82 (47%) were spouses. The ratio of the time actually allowed
to family members over the time they would have liked to
spend receiving information was 0.66 (0.5 to 1), and the differ-
ence between the desired and actual times was 5 minutes (0 to
7.75). Twenty-nine (17%) family members reported receiving
contradictory information, 89 (51%) did not know the specific
role of each caregiver, 90 (51%) were not receiving help from
their usual doctor, and 68 (39%) expressed a desire to receive
help from a psychologist. One hundred sixty-five family mem-
bers (94%) were satisfied with the information provided by
TABLE 1. CHARACTERISTICS OF THE ICUs (n  34)
Number (%) or
Parameters Median (quartiles)
University hospital 15 (44.1)
Number of beds per unit 13 (7.25–16)
Waiting room available 27 (79.4)
Room for family information available 20 (58.8)
Number of attending physicians 3 (2–4)
Number of junior physicians 2 (1–3.75)
Nurse-to-patient ratio 3 (3–3.37)
Regular nurse–physician meetings about family information 16 (47)
Total daily visiting hours, min 120 (97–180)
Written protocol for interacting with families 4 (11.8)
FIL available (before the study) 26 (76.5)
Information to each family always given by same physician 6 (17.6)
440 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 165 2002

TABLE 2. CHARACTERISTICS OF PATIENTS (n  175)* tween the two groups. As shown in Table 4, comprehension
All Patients No Leaflet Leaflet
was significantly better in the FIL group (11.5 versus 41% of
Variable (n  175) (n  88) (n  87) p Value family members with poor satisfaction, p  0.0001).
Satisfaction did not differ significantly between the FIL
Age 60 (48–71) 61 (51–70) 57 (47–73) NS
and the control groups (median score, 21 [18 to 26] versus 23
Sex ratio, % women 62 (35.4) 30 (34) 32 (36.8) NS
Patients of French descent 136 (77.7) 68 (77.3) 68 (78.1) NS
[19 to 27], p  0.08). However, among family members with
Unmarried 32 (18.3) 12 (13.6) 20 (22.9) NS good comprehension, those who received the FIL had a signif-
Unemployed 31 (17.7) 16 (18.2) 15 (17.2) NS icantly better median satisfaction score than those who did not
Direct admission 43 (24.6) 21 (23.8) 22 (25.3) NS (21 [18 to 24] versus 27 [24 to 29], p  0.01) (Figure 2). Anxi-
ICU admission for ety and depression were not significantly less prevalent in the
Acute respiratory failure 99 (56.6) 48 (54.5) 51 (58.6) NS
FIL group. Moreover, the number of physician–family meet-
Shock 57 (32.6) 29 (32.9) 28 (32.2) NS
Acute renal failure 40 (22.8) 20 (22.7) 20 (23) NS
ings per patient was similar in the FIL group and in the control
Coma 66 (37.7) 31 (35.2) 35 (40.2) NS group (3 [2 to 5] versus 3 [1 to 4], respectively).
SAPS II 41 (29–55) 42 (30–55) 40 (27–54) NS
Length of ICU stay 9 (6–17) 10 (6–16) 9 (6–18) NS
ICU mortality rate 44 (25.1) 21 (23.9) 23 (26.4) NS
DISCUSSION
Definition of abbreviation: NS  not significant. Effective communication and a collaborative relationship be-
* Values are expressed as number (%) or median (ranges). tween ICU caregivers and their patients’ family members are
vital components of quality care (1–4, 9, 13, 14) and of compli-
ance with accreditation requirements (4). We report the first
junior physicians. According to the Hospital Anxiety and De- multicenter prospective randomized controlled study of an in-
pression Scale (HADS), 105 (60%) family members suffered tervention designed to improve the effectiveness of informa-
anxiety and 68 (39%) depression. None of these parameters tion provided by ICU caregivers to the family members of
was significantly different between the two randomized groups. their patients. A simple, easily produced leaflet significantly
improved comprehension by family members. Moreover, in
Comprehension and Satisfaction the subset of patients with good comprehension, the leaflet
Failure to comprehend the diagnosis, prognosis, or treatment improved satisfaction. This leaflet both provided information
was noted in 46 (26%) family members; 16 (9%) did not un- and extended an invitation to talk with ICU caregivers.
derstand the diagnosis, 18 (10%) the prognosis, and 37 (21%) Comprehension of and satisfaction with the information
the treatment. The median satisfaction score was 22 (19 to provided by ICU caregivers are essential if family members
26.5). Patients who understood the diagnosis, prognosis, and are to be not simply visitors to the ICU (13), but participants
treatment had a significantly lower CCFNI score, indicating in some of the aspects of the patient’s care and a source of in-
better satisfaction (21 [19 to 25] versus 25 [19 to 28], p  0.04). formation about the patient’s wishes (5, 12, 15).
Symptoms of anxiety and depression were associated neither Using our criterion of comprehension, about one-quarter
with comprehension nor with satisfaction. of the family members overall did not understand the diagno-
sis, prognosis, or treatment in the patient. This is only half the
Impact of the FIL on Comprehension and Satisfaction proportion in an earlier study (1), suggesting that efforts made
Tables 1–3 show that characteristics of the ICUs, the patients, in recent years to improve family management have met with
and the family members were not significantly different be- some success (10, 15–17). Analysis of comprehension assessed

TABLE 3. CHARACTERISTICS OF FAMILY REPRESENTATIVES*

All Representatives No Leaflet Leaflet p

Variable (n  175) (n  88) (n  87) Value

Age 49 (37–62) 50 (40–61) 46 (35–63) NS

Sex ratio, % women 49 (28) 23 (26.1) 26 (29.9) NS
Health care professionals 9 (5.1) 4 (4.5) 5 (5.7) NS
Family representatives of French descent 135 (77.1) 66 (75) 69 (79.3) NS
Relationship with the patient
Spouse 82 (46.8) 44 (50) 38 (43.7)
Parent 13 (7.4) 6 (6.8) 7 (8)
Child 49 (28) 25 (28.4) 24 (27.6) NS
Sibling 21 (12) 8 (9) 13 (14.9)
Other relatives 5 (2.8) 2 (2.3) 3 (3.5)
Not a relative 5 (2.8) 3 (3.4) 2 (2.3)
Hospital commuting time, min 30 (18–60) 45 (16–60) 30 (20–45) NS
Allowed/desired information time ratio 0.66 (0.5–1) 0.66 (0.5–1) 0.66 (0.5–1) NS
Representatives who felt they received contradictory information 29 (16.6) 17 (19.3) 12 (13.8) NS
Representatives who would have liked more information about
Diagnosis 113 (66.6) 61 (69.3) 52 (59.7)
Prognosis 110 (62.8) 56 (63.6) 54 (62) NS
Treatment 112 (64) 59 (67) 53 (60.9)
Representatives who did not know the specific role of each caregiver 89 (50.8) 51 (57.9) 38 (43.6) NS
Representatives not receiving help from their usual doctor 90 (51.4) 50 (56.8) 40 (45.9) NS
Representatives who would have liked help from a psychologist 68 (38.8) 36 (40.9) 32 (36.8) NS
Number of physician–family meetings between ICU admission and
comprehension assessment 3 (2–5) 3 (1–4) 3 (2–5) NS

* Values are expressed as number (%) or median (ranges).

Azoulay, Pochard, Chevret, et al.: Family Information Leaflet
TABLE 4. EVALUATION OF THE EFFECTIVENESS OF THE INFORMATION PROVIDED TO REPRESENTATIVES
OF ICU PATIENTS*
All Representatives
(n  175)
Poor comprehension 46 (26.3)
Poor comprehension of the diagnosis 16 (9.1)
Poor comprehension of the prognosis 18 (10.3)
Poor comprehension of the treatment 37 (21.1)
Satisfaction score (CCFNI)† 22 (19–26.5)
Definition of abbreviation: CCFNI  Critical Care Family Needs Inventory.
* Values are expressed as number (%) or median (ranges).
†
This score can range from 14 (extreme satisfaction) to 56 (extreme dissatisfaction) (5). Satisfactory comprehension of the diagnosis
was defined as knowledge of which organ was primarily involved in the disease process; satisfactory comprehension of the prognosis as
knowledge of whether the patient was expected to survive (not grave) or not (grave); and satisfactory comprehension of the treatment as
knowledge of at least one of the major treatments used among the list of 10 given by the physicians (1).
by the ICU investigators, who were blinded to group assign-
ment of family representatives, showed that the FIL reduced
the proportion of patients with poor comprehension to ap-
proximately 11%. However, the leaflet improved the compre-
hension of diagnosis and treatment but not of prognosis, re-
flecting the focus of our leaflet on diagnosis and treatment,
and confirming previous reports that understanding the prog-
nosis is difficult (18, 19). The prognosis is often more difficult
to determine than the correct diagnosis and appropriate treat-
ment, and this uncertainty may complicate the delivery of eas-
ily understandable information on this point. The dichoto-
mous classification of the prognosis as “grave” or “not grave”
used to inform family members in our study can by no means
be viewed as a basis for decision-making in the ICU, but may
help families to develop reasonable expectations and to set
their coping strategies in motion.
In our study, the leaflet was used in combination with in-
formation imparted during face-to-face interviews. Conse-
quently, our results should not be construed as meaning that
written information used alone can improve comprehension.
The criterion for good comprehension used in this study has
been validated (1). It involves relatively limited knowledge of
the patient’s condition. No criterion standard is available for
assessing comprehension in family members of ICU patients.
We selected a criterion involving limited comprehension be-
cause we believe that families cannot be expected to fully grasp
all the facets of the patient’s condition based only on informa-
tion given during a brief period after ICU admission.
In the ICU, positive interaction between caregivers and
family members requires an open exchange of information
aimed both at helping family members cope with their distress
and at allowing them to speak for the patient if necessary. Our
findings indicate that an FIL improves this exchange of infor-
mation. Earlier data suggest that a leaflet may be perceived by
families as a message of welcome extended by ICU caregivers
Figure 2. Impact of the FIL
on satisfaction in family mem-
bers with good comprehen-
sion. CCFNI score ranged from
14 (entire satisfaction) to 56
(entire dissatisfaction) (5). p 
0.01 using the Mann-Whit-
ney test.  Bad comprehen-
sion, no leaflet; bad com-
prehension, with leaflet;
good comprehension, no leaf-
let;  good comprehension,
with leaflet.
441
No Leaflet Leaflet
(n  88) (n  87) p Value
36 (40.9) 10 (11.5)  0.0001
13 (14.7) 3 (3.4) 0.02
11 (12.5) 7 (8) 0.20
31 (35.2) 6 (6.9)  0.0001
23 (19–27) 21 (18–26) 0.08
(1, 11) who place meeting the needs of families among their
priorities (6, 15, 16, 20). However, one aspect of the leaflet
used in our study was an invitation to talk with ICU care-
givers. Talking more with the caregivers may provide opportu-
nities to obtain information in addition to that contained in an
FIL, thereby improving comprehension. However, we found
no difference between the FIL and control groups regarding
the number of physician–family meetings. Our finding that the
FIL improved comprehension without providing information
specific to the patient is in agreement with the hypothesis that
efforts should be made upstream to the ICU to improve the
general knowledge of family members about ICU operation
and vocabulary. Information specific to the patient may be
less likely to be grasped by family members.
Good comprehension was associated with better satisfac-
tion. Although satisfaction was not significantly associated
with delivery of the FIL, among patients with good compre-
hension those who received the leaflet had significantly better
satisfaction scores than those who did not. These data suggest
two important interpretations. First, comprehension did not
generate dissatisfaction: this runs counter to the hypothesis
that poor satisfaction may be related to the seriousness of the
patient’s condition in family members who would prefer to
deny reality, i.e., to an unwillingness of the family to take in
the information that is given to them. Second, comprehension
is a foundation from which other benefits, such as better satis-
faction, can arise: family members with good comprehension
are more likely to benefit from the efforts made by ICU care-
givers to meet their needs.
The prevalence of anxiety and depression in family mem-
bers may be useful for evaluating the quality of information
provided by caregivers to family members of ICU patients.
We previously reported that both symptoms were common in
family members (21). Nevertheless, the impact of these symp-
toms on the decision-making capacity of family members has
not been evaluated. The present study confirms the extremely
high rates of anxiety and depression in family members of
ICU patients. Above all, it demonstrates that anxiety and de-
pression measured 3 to 5 d after ICU admission are indepen-
dent from comprehension and satisfaction. This strongly sug-
gests that family members experience anxiety and depression
because the patient is in an ICU, not as a response to informa-
tion so painful that they cannot cope with it.
Meeting the needs of family members of ICU patients and
improving their comprehension is of great importance for sev-
eral reasons. First, more and more families are asking to par-
ticipate in medical decisions (10, 17, 20). If caregivers and fam-
ily members are to work together to determine what is best
for the patient, then the family members must have a reason-
able level of comprehension of the patient’s problem and be
442 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE
reasonably satisfied with the ICU. Comprehension and satis-
faction can be evaluated using previously reported criteria (1–
3, 5, 12, 16). Second, few patients in the United States and in
Europe have living wills or advance directives (22–24). Conse-
quently, when patients are unable to speak for themselves,
their families are asked about their wishes. Third, information
helps family members to cope with their distress, to build rea-
sonable expectations about the patient’s outcome, and to per-
ceive the ICU as a welcoming place where they can wait with
relative peace of mind for events to unfold (1, 10, 18). More-
over, our study indicates that understanding information pro-
vided by caregivers does not generate anxiety or depression.
We evaluated the impact of our leaflet on only one family
member of each patient, selected as the patient’s representa-
tive by the patient or by all available family members. In ev-
eryday practice, we believe that each family member should
receive the leaflet and that ICU caregivers should check that
the information is passed on to other family members (25, 26).
In conclusion, a family information leaflet significantly im-
proved comprehension. ICU caregivers should hand a leaflet
to family members at their first visit to the ICU. Further inter-
ventional studies are needed to identify and evaluate other
means of improving the quality of information provided to
family members of ICU patients.
Acknowledgment : The authors are indebted to A. Wolfe, M.D., for her help
in preparing this manuscript.
References
1. Azoulay E, Chevret S, Leleu G, Pochard F, Barboteu M, Adrie C,
Canoui P, Le Gall JR, Schlemmer B. Half the families of intensive
care unit patients experience inadequate communication with physi-
cians. Crit Care Med 2000;28:3044–3049.
2. Azoulay E, Pochard F, Chevret S, Lemaire F, Mokhtari M, Le Gall JR,
Dhainaut JF, Schlemmer B, for the French FAMIREA group. Meet-
ing the needs of ICU-patients’ families: a multicenter study. Am J
Respir Crit Care Med 2001;163:135–139.
3. Johnson D, Wilson M, Cavanaugh B, Bryden C, Gudmundson D, Mood-
ley O. Measuring the ability to meet family needs in an intensive care
unit. Crit Care Med 1998;26:266–271.
4. Harvey MA, Ninos NP, Adler DC, Goodnough-Hanneman SK, Kaye
WE, Nikas DL. Results of the consensus conference on fostering more
humane critical care: creating a healing environment. Society of Criti-
cal Care Medicine. AACN Clin Issues Crit Care Nurs 1993;4:484–549.
5. Molter NC. Needs of relatives of critically ill patients: a descriptive
study. Heart Lung 1979;8:332–339.
6. Lilly CM, De Meo DL, Sonna LA, Haley KJ, Massaro AF, Wallace RF,
Cody S. An intensive communication intervention for the critically ill.
Am J Med 2000;109:469–475.
VOL 165 2002
7. Devlin J. Pain assessment in the seriously ill patient: can family members
play a role? Crit Care Med 2000;28:1660–1661.
8. Novaes MA, Knobel E, Bork AM, Pavao OF, Nogueira-Martins LA,
Ferraz MB. Stressors in ICU: perception of the patient, relatives and
health care team. Intensive Care Med 1999;25:1421–1426.
9. Larson CO, Nelson EC, Gustafson D, Batalden PB. The relationship be-
tween meeting patients’ information needs and their satisfaction with
hospital care and general health status outcomes. Int J Qual Health
Care 1996;8:447–456.
10. Maillet RJ, Pata I, Grossman S. A strategy for decreasing anxiety of ICU
transfer patients and their families. Nursingconnections 1993;6:5–8.
11. McGaughey J, Harrison S. Developing an information booklet to meet
the needs of intensive care patients and relatives. Intensive Crit Care
Nurs 1994;10:271–277.
12. Henneman EA, McKenzie JB, Dewa CS. An evaluation of interventions
for meeting the information needs of families of critically ill patients.
Am J Crit Care 1992;1:85–93.
13. Molter NC. Families are not visitors in the critical care unit. Dimens Crit
Care Nurs 1994;13:2–3.
14. Jastremski CA, Harvey M. Making changes to improve the intensive
care unit experience for patients and their families. New Horiz 1998;
6:99–109.
15. Medland JJ, Ferrans CE. Effectiveness of a structured communication
program for family members of patients in an ICU. Am J Crit Care
1998;7:24–29.
16. Bernat Adell MD, Tejedor Lopez R, Sanchis Munoz J. [How well do pa-
tients’ relatives evaluate and understand information provided by the
intensive care unit?]. Enferm Intensiva 2000;11:3–9.
17. Robinson SM, Mackenzie-Ross S, Campbell Hewson GL, Egleston CV,
Prevost AT. Psychological effect of witnessed resuscitation on be-
reaved relatives. Lancet 1998;352:614–617.
18. Randolph AG, Guyatt GH, Calvin JE, Doig G, Richardson WS. Under-
standing articles describing clinical prediction tools. Evidence Based
Medicine in Critical Care Group. Crit Care Med 1998;26:1603–1612.
19. Randolph AG, Guyatt GH, Richardson WS. Prognosis in the intensive
care unit: finding accurate and useful estimates for counseling pa-
tients. Crit Care Med 1998;26:767–772.
20. Daly K, Kleinpell RM, Lawinger S, Casey G. The effect of two nursing in-
terventions on families of ICU patients. Clin Nurs Res 1994;3:414–422.
21. Pochard F, Azoulay E, Chevret S, Lemaire F, Hubert P, Canoui P, Zit-
toun R, Le Gall JR, Dhainaut JF, Schlemmer B, for the FAMIREA
group. Anxiety and depression in families of ICU patients: ethical con-
siderations for decision making capacities. Crit Care Med 2001;29:1893–
1897.
22. Most elderly people inpatients haven’t heard of living wills. Br Med J
2000;320:E.
23. Hanson LC, Rodgman E. The use of living wills at the end of life. A na-
tional study. Arch Intern Med 1996;156:1018–1022.
24. Small H. Increasing completion of advance directives. JAMA 1994;271:
1907–1908.
25. Pochard F, Grassin M, Herve C. Palliative options at the end of life.
JAMA 1998;279:1065–1067.
26. Pochard F, Grassin M, Azoulay E. Ethical principles for everyone. Ann
Intern Med 2001;134:1152–1153.